keratoconus jurnal

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CORNEA

Anterior stromal puncture for treatment

of contact lens-intolerant keratoconus patients

Su Yeon Kang &Young Kee Park &Jong-Suk Song &

Hyo Myung Kim

# Springer-Verlag 2010

Abstract

Purpose To report the results and effectiveness of anteriorstromal puncture for contact lens-intolerant keratoconus

patients with subepithelial fibrotic nodules.

Methods Nine eyes of nine keratoconus patients who were

rigid gas-permeable contact lenses (RGP)-intolerant due to

subepithelial nodular scars were included in this study. The

nine patients were enrolled in the study between March 2008

and December 2008. After confirming nodular elevation from

slit-lamp biomicroscopy, the area where the epithelium of

nodular scars had sloughed was punctured by anterior stromal

puncture using a 26-gauge needle attached to a 1-ml syringe

under slit-lamp biomicroscopy. The RGPs of all patients were

refitted around 4 weeks after the puncture.Results Five of the nine patients were male, and the

average patient age was 29.6 years (SD5.22 years). Mean

follow-up time was 13.7 months (SD4.8 months), and the

epithelial defect healed in 1.4 days on average. After the

puncture, four of nine patients presented with a recurrent

erosion of the nodule during follow-up and needed a second

puncture. All the patients showed good contact lens

tolerance and satisfactory contact lens fit. No complications

such as corneal perforation or keratitis developed.Conclusions Anterior stromal puncture using a 26-gauge

needle can be a successful and effective method to induce

corneal epithelium and Bowmans layer reattachment. It can be

used as an outpatient procedure to improve RGP tolerance in

patients with keratoconus with elevated subepithelial nodules.

Keywords Anterior stromal puncture . Keratoconus .

Keratoconus nodules . Contact lens intolerant

Keratoconus is a noninflammatory condition where the cornea

assumes a conical shape because of thinning and protrusion of

the corneal stroma [1]. The corneal thinning induces irregular

astigmatism, myopia, and protrusion, leading to mild to

marked impairment in the quality of vision. Symptoms are

highly variable and, in part, depend on the stage of

progression of the disorder [1]. Early in the disease, there

may be no symptoms, but in advanced disease there is

significant distortion of vision accompanied by profound

visual loss [1]. The management of keratoconus varies

depending on the stage of progression of the disease. In very

early keratoconus cases, spectacles may provide adequate

visual correction, but because spectacles do not conform to the

unusual shape of the cornea and the resultant induced irregular

astigmatism, contact lenses provide better correction, and are

therefore the mainstay of therapy in keratoconus [1]. About

80% of all patients with keratoconus use spectacles, soft toric

contact lenses, or rigid gas-permeable contact lenses (RGPs;

the majority of patients) to successfully correct their vision [2].

However, contact lens intolerance in keratoconus some-

times occurs due to the formation of raised subepithelial

nodular scars [3, 4]. These subepithelial nodular scars,

which are also referred to as proud nebulae [3], are

The authors have no proprietary, commercial, or financial interests inany of the products described in this study.

S. Y. Kang:

J.-S. Song:

H. M. Kim (*)Department of Ophthalmology, Guro Hospital,Korea University College of Medicine,80, Guro-dong, Guro-gu,Seoul 152-703, South Koreae-mail: [email protected]

S. Y. Kange-mail: [email protected]

Y. K. ParkDr. Lee&Parks Eye Clinic,Seoul, South Korea

DOI 10.1007/s00417-010-1423-9

Graefes Arch Clin Exp Ophthalmol (2011) 249:8992

Received: 18 February 2010 /Revised: 9 May 2010 /Accepted: 14 May 2010 /Published online: 13 July 2010


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typically at or near the apex of the cone [5]. These nodules

can result in contact lens intolerance because of recurrent

erosions and discomfort [6]. Although the erosions heal

after a period without contact lens wear, the nodules remain

elevated and may persist even after prolonged periods

without lens wear [7]. Patients with these nodules often

require more invasive procedures, including corneal trans-

plantation, to correct their vision.Various treatment options have been used to treat these

nodular scars successfully, including manual superficial

keratectomy and excimer laser phototherapeutic keratec-

tomy (PTK) [4, 6, 8, 9]. Although successful, these

techniques require expensive equipment in an operative

setting. In this study, we investigated the efficacy of

anterior stromal puncture under slit-lamp biomicroscopy

for treatment of recurrent corneal erosions, with the

rationale that the puncture would enhance adherence of

the epithelium to the basement membrane [10]. To the best

of our knowledge, this is the first report of successful

treatment of subepithelial nodules in keratoconus usinganterior stromal puncture.

Materials and methods

Patients were referred from the keratoconus clinic of Dr.

Lee&Parks clinic to the the contact lens and cornea

department of Ophthalmology, Korea University College of

Medicine, Seoul. A total of nine eyes from nine referred

keratoconus patients who were RGP-intolerant due to the

presence of subepithelial nodules were treated using anterior

stromal puncture between March 2008 and December 2008.

In all patients, the subepithelial nodules were slightly down

to the visual axis, and had failed to flatten either on refitting

or discontinuing contact lens wear. Contact lenses were fitted

according to the three-point touch technique with a light

apical touch.

All patients had previously worn RGP lenses and had

achieved good visual acuity with these lenses. On slit-lamp

examination, we confirmed the presence of an elevated

subepithelial nodule with sloughed epithelium near the apex

of the cone in all patients (Fig. 1a, b). Corneal topography

(ORBScan, Orbttek Inc.) was performed for all cases.

However, useful data was not obtained in some patients

because of the irregularity of the tear film and epithelium.

Informed consent was provided by all study participants,

and the principles outlined in the Declaration of Helsinki

were followed in this study.

Procedure for anterior stromal puncture

A topical anesthetic eyedrop (Alcaine, proparacaine

hydrochloride 0.5%, Alcon) was instilled. After confirming

the sloughed epithelium of the elevated nodular scars,

multiple anterior stromal punctures were made to the

elevated nodular scar area under slit-lamp biomicroscopy

while the patient was in a seated position. The number of

punctures varied according to the size of the area. We used

a bent 26-gauge (0.10.2 mm turned end) needle attached

to a 1-ml disposable syringe. After the treatment, an

antibiotic eyedrop (Cravit, levofloxacin 0.5%, Santen)was instilled, and an eye patch was worn until the day after

the procedure. The patients were instructed to follow-up

daily until the epithelium had healed, and to use antibiotic

eyedrops every 6 hours for 1 week for prophylaxis. All the

patients were refitted with RGPs approximately 4 to

6 weeks after the procedure, which is when we expected

surgical healing to be complete and the scar to have formed.

Results

We investigated nine eyes from five men and four women(Table 1). The mean age of the patients was 29.6 years

5.22 (SD) (range 22 to 36 years). The mean follow-up

time was 13.7 months 4.8 (SD). Patients experienced no

pain during the procedure, and reported minimal discomfort

for up to 24 hours after the procedure, with no requests for

analgesics. The epithelial defects healed in 1.4 days on

average (range 12 days), and four of the nine eyes had an

epithelial defect on the first post-procedure day.

In all cases, successful anterior stromal punctures were

performed; no complications such as corneal perforation or

keratitis developed. Approximately 4 to 6 weeks after the

procedure, all patients were refitted with RGPs and

achieved corrected visual acuity. However, four of nine

patients developed a recurrent erosion of subepithelial

nodule after RGP refitting, and required a second puncture.

The procedure was reported in all these patients as

described above, and no further recurrences were observed

during the follow-up period. No patients underwent

penetrating keratoplasty during the follow-up period.

Discussion

To remove keratoconus subepithelial nodules and to

improve contact lens intolerance, several treatment options

have been reported, including manual superficial keratec-

tomy and excimer laser phototherapeutic keratectomy

(PTK) [3, 69]. Excimer laser PTK is a successful

treatment procedure for anterior corneal pathology, and

has several advantages over surgical excision [3, 6]. Laser

patients experience much less postoperative pain, and the

resultant wound is much smaller and more regular than that

made during surgical excision [3]. An early report by

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Steinert and Puliafito [9] stated that PTK could be used to

successfully remove keratoconus nodules. These authors

reported that the patient was able to refit his/her contact

lens 2 weeks after the procedure, with a visual acuity of 20/

25; this visual acuity remained stable for the entire 6-week

follow-up period. In another study by Moodaley et al. [3],.

excimer laser PTK was used to remove keratoconusnodules in ten patients, and seven patients were able to

resume regular contact lens wear within 1 month of

completion of treatment. All patients achieved a postoper-

ative visual acuity of 6/12 or better with a contact lens at

the end of the 8-month follow-up period. Elsahn et al. [6].

recently reported on a larger series of 15 patients with a

longer follow-up period of 23 months who underwent

successful PTK for keratoconus nodules.

However, several investigators have reported a variety of

complications after PTK procedures. Lahners et al. [5].

reported a case of keratolysis following PTK for a

subepithelial nodule in a patient with keratoconus; progres-sive keratolysis led to a central descemetocele. Infections

such as bacterial keratitis [11] and herpes simplex keratitis

[12] have also been reported, though the incidence of these

is low. In some patients, a hyperopic shift induced by PTK

has been observed [13, 14]. Other possible complications

after the PTK procedure include delayed reepithelialization

and recurrent erosions, scarring, and irregular astigmatism

[15,16].

In this study, we report the successful treatment of

subepithelial nodules in the eyes of nine keratoconus

patients, using anterior stromal puncture with a 26-gauge

needle. Anterior stromal puncture is a treatment used for

recurrent corneal erosions, as the punctures enhance

epithelium adhesion to the basement membrane due to scar

formation [10]. Anterior stromal puncture has someadvantages over PTK for treating recurrent corneal erosion.

It can be performed in an outpatient and office setting

without the requirement for expensive equipment like an

excimer laser; there is a very low risk of inducing visually

significant corneal scarring and hyperopic shifts, and the

epithelial healing time is much shorter [17]. In keratoconus

patients, contact lens wear usually abrades the epithelium of

the subepithelial nodule, and the patient may be unable to

wear the contact lens because of discomfort [3]. In all cases

in this study, we confirmed that sloughed epithelium from

the subepithelial nodule made contact lens intolerable, and

made anterior stromal punctures to ensure more securebonding of the epithelium, similar to the treatment used for

recurrent corneal erosion patients.

In conclusion, anterior stromal puncture using a 26-

gauge needle is a successful and effective method for

inducing corneal epithelium and Bowmans layer reattach-

ment. This procedure can improve RGP tolerance in

patients with keratocon us with elevated subepithelial

nodules in an outpatient office setting.

Fig. 1 a. Slit-lamp photographs of a subepithelial nodule in a patient with keratoconus before anterior stromal puncture. Note the elevated noduleat the apex of cone (slit lamp; slit view, 16). b Fluorescein staining in the subepithelial scar area due to elevated epithelium of the nodule

Patient No Age (years) Sex Eye K1 Axis K2 Axis VAa (with RGP)

1 33 M OS 59.2 140 53.7 50 20/25

2 30 F OD 71.1 5 65.6 95 20/25

3 30 F OS Not b - - - 20/25

4 36 F OD 64.0 4 59.1 94 20/40

5 23 M OS Not - - - 20/30

6 26 M OD 51.7 109 47.4 19 20/20

7 22 M OS Not - - - 20/25

8 31 M OS 65.9 106 56.0 16 20/25

9 25 F OS Not - - - 20/25

Table 1 Preoperative patientdata

aVA, visual acuity

bNot applicable due to irregular

corneal surface

91Graefes Arch Clin Exp Ophthalmol (2011) 249:8992


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